Provider Demographics
NPI:1922038561
Name:MLS 1116 INC
Entity Type:Organization
Organization Name:MLS 1116 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKEMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:270-634-0534
Mailing Address - Street 1:702 COLUMBIA HWY
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:42743-1118
Mailing Address - Country:US
Mailing Address - Phone:270-973-5276
Mailing Address - Fax:270-973-5267
Practice Address - Street 1:702 COLUMBIA HWY
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743-1118
Practice Address - Country:US
Practice Address - Phone:270-973-5276
Practice Address - Fax:270-973-5267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90004037Medicaid
KY4221850001Medicare NSC